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Medication mix-up causes death of shoulder surgery patient

Unlabeled syringes and medications endanger patient safety

An academic orthopedic surgeon who’s part of a medical school faculty was recently ordered to get more training for remedial education by a state medical board over operating room care. What happened that led to this?

A patient—we’ll call him Bill—was a man in his late 50s who went to an ambulatory surgery center (ASC) for left shoulder arthroscopy (shoulder surgery) with rotator cuff repair.

Before the surgery began, the operating room (OR) team observed a surgical time-out or huddle.

Healthcare accrediting agency The Joint Commission introduced this requirement years ago out of recognition that operating rooms are busy places and it’s helpful to patient safety to focus everyone’s attention. The team discussion focuses on identifying the correct patient, correct procedure, and correct location, as well as other details about the surgical plan.

During the surgical time-out, a nurse asked the surgeon how she’d like the epinephrine prepared.

Epinephrine is a powerful medication that’s commonly used during arthroscopic shoulder surgery. It’s often given with a local anesthetic, such as Marcaine, to help with bleeding and control pain after the surgery.

The surgeon told the nurse that she’d like the epinephrine and Marcaine to be mixed “on the field,” which means at the OR table during the procedure. That would involve a scrub tech in the OR mixing around 30 mL of Marcaine with a small amount of epinephrine. Remember the number 30 mL because it’s significant to the story.

The Joint Commission has also identified medication handling as a common danger to patient safety. That’s why, in 2021, it implemented a National Patient Safety Goal requiring all medications and containers, including syringes, to be labeled. The labeling must include the medication name, strength, and amount if they’re not immediately administered.

At this surgery center, though, the OR staff didn’t label medications in syringes.

On this particular date, the nurse gave the scrub technician a 30 mL vial of epinephrine. The scrub tech then drew all 30 mL into a 30 mL (30 cc) syringe and placed it on the OR table without a label.

When the scrub tech walked away from the table, the surgeon thought the unlabeled 30 ml (30 cc) syringe was the proper Marcaine-epinephrine mixture, but it wasn’t—it was a large dose of pure epinephrine. The surgeon injected Bill with the full contents of the syringe and Bill quickly developed an abnormal heart rhythm and a Code was called. Bill died despite life-saving measures.

Operating rooms are busy places and are dangerous to patients when surgeons, nurses, anesthesia personnel (anesthesiologists and certified registered nurse anesthetists/CRNAs), and surgical techs don’t follow basic safety rules. If you or someone you care for has been seriously injured in Texas because of poor OR care, then contact a top-rated, experienced Texas medical malpractice attorney for a free strategy session about your potential case.

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him by calling 281-580-8800 or emailing him right now.


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